# NTSB ERA15CA107: Piper PA-28-161, N104SA, Alexander City, AL, January 19, 2015

- Type: NTSB accident investigation
- Classification: Accident · Minor injuries · Data collection · Final report
- Date: January 18, 2015, 18:30 local (Jan 19, 2015, 00:30 UTC)
- Place: Alexander City, AL
- Coordinates: 32.914722, -85.962776 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=32.9147&lon=-85.9628&mi=10
- Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping)
- Defining event: [Standing-engine(s) start-up: Loss of control on ground](https://openairdocs.org/ntsb-events/230)
- Highest injury: Minor injuries
- Injuries: 1 minor
- Status: Completed, report July 8, 2015
- Report: Approved by Office Director
- NTSB office: Eastern Region Aviation
- Parties: FAA / FSDO
- NTSB case key (mKey): 90620
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA15CA107
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/90620/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=90620
- Page: https://openairdocs.org/ntsb/ERA15CA107

## Probable cause

The pilot's failure to properly secure the airplane before hand-propping the engine for startup.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Electrical power system: battery/charger](https://openairdocs.org/ntsb-findings/01022432): Aircraft › Aircraft systems · Incorrect service/maintenance; cases with it: [Piper PA-28-161, 1 case](https://openairdocs.org/ntsb-findings/01022432/cases.md?model=7102803), [All aircraft, 37 cases](https://openairdocs.org/ntsb-findings/01022432/cases.md)
- [Electrical power system: battery/charger](https://openairdocs.org/ntsb-findings/01022432): Aircraft › Aircraft systems · Failure; cases with it: [Piper PA-28-161, 1 case](https://openairdocs.org/ntsb-findings/01022432/cases.md?model=7102803), [All aircraft, 37 cases](https://openairdocs.org/ntsb-findings/01022432/cases.md)
- [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28-161, 8 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=7102803), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md)
- [Parking/securing: tie-down/mooring](https://openairdocs.org/ntsb-findings/01011020): Aircraft › Aircraft handling/service · Incorrect use/operation (probable cause); cases with it: [Piper PA-28-161, 1 case](https://openairdocs.org/ntsb-findings/01011020/cases.md?model=7102803), [All aircraft, 33 cases](https://openairdocs.org/ntsb-findings/01011020/cases.md)
- [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-161, 40 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102803), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Other: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Piper PA-28-161, 2 cases](https://openairdocs.org/ntsb-events/040/sequence.md?model=7102803), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md)
- [Standing-engine(s) start-up: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Piper PA-28-161, 20 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=7102803), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md)
- [Standing-engine(s) operating: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Piper PA-28-161, 13 cases](https://openairdocs.org/ntsb-events/060/sequence.md?model=7102803), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md)
- [Taxi: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-161, 58 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102803), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)

## Analysis

On the day of the accident, the pilot had to get the airplane jumpstarted as the battery was low on energy. Later during his flight home, he landed at an airport to refuel. After refueling, he attempted to start the engine. The battery however, was too weak to start the engine. The pilot then checked the parking brake was engaged and got out to look for his portable jump starter pack in the storage compartment. It was not however onboard. He then proceeded to look for someone to assist in starting. Not finding anyone, he went back to the airplane and set the mixture to full rich, opened the throttle about 10 percent, primed the engine about 8 to 10 times, turned the magneto switch to "BOTH", checked the parking brake, and attempted to hand-prop the engine twice without success. He then checked these items again and once again attempted to hand-prop the engine. The engine still failed to start. He assumed the engine was flooded. Therefore, he set the mixture to idle cutoff, turned off the magnetos, and checked the parking brake once again. He then got out of the aircraft and prior to touching the propeller, visually looked in the cabin to check that the key for the magneto switch wasn't in the "BOTH" position. He then hand-propped it. A puff of smoke came out of the exhaust, and the engine suddenly accelerated to maximum rpm. He immediately moved from in front of the propeller. He then thought "the brakes are on, don't worry", then noticed that the airplane was moving and picking up speed. At this point, he was in front of the right wing. He then attempted to grab hold of the door, hop on wing and get into the airplane. He could not however get a grip on door as the slipstream from the propeller pushed it shut. He was then dragged and run over by the airplane. The airplane then made contact with a ditch and was substantially damaged. The pilot advised that he had been having problems with the battery holding a charge, and that he should have replaced it. He also advised that apparently one magneto was still on; he should have used chocks, and should not have attempted to hand-prop it by himself.

## Factual narrative

On the day of the accident, the pilot had to get the airplane jumpstarted as the battery was low on energy. Later during his flight home, he landed at an airport to refuel. After refueling, he attempted to start the engine. The battery however, was too weak to start the engine. The pilot then checked the parking brake was engaged and got out to look for his portable jump starter pack in the storage compartment. It was not however onboard. He then proceeded to look for someone to assist in starting. Not finding anyone, he went back to the airplane and set the mixture to full rich, opened the throttle about 10 percent, primed the engine about 8 to 10 times, turned the magneto switch to "BOTH", checked the parking brake, and attempted to hand-prop the engine twice without success. He then checked these items again and once again attempted to hand-prop the engine. The engine still failed to start. He assumed the engine was flooded. Therefore, he set the mixture to idle cutoff, turned off the magnetos, and checked the parking brake once again. He then got out of the aircraft and prior to touching the propeller, visually looked in the cabin to check that the key for the magneto switch wasn't in the "BOTH" position. He then hand-propped it. A puff of smoke came out of the exhaust, and the engine suddenly accelerated to maximum rpm. He immediately moved from in front of the propeller. He then thought "the brakes are on, don't worry", then noticed that the airplane was moving and picking up speed. At this point, he was in front of the right wing. He then attempted to grab hold of the door, hop on wing and get into the airplane. He could not however get a grip on door as the slipstream from the propeller pushed it shut. He was then dragged and run over by the airplane. The airplane then made contact with a ditch and was substantially damaged. The pilot advised that he had been having problems with the battery holding a charge, and that he should have replaced it. He also advised that apparently one magneto was still on; he should have used chocks, and should not have attempted to hand-prop it by himself.

## Aircraft

- Registration: [N104SA](https://openairdocs.org/deregistered/N104SA-2018-01-03), registration cancelled 2018-01-03, S/N 28-8016165, built 1979 (OpenAirDocs)
- Reported make and model: PIPER PA-28-161
- Registry model: [Piper PA-28-161](https://openairdocs.org/model/piper-pa-28-161) (registry code 7102803) (OpenAirDocs)
- Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 28-8016165
- Year built: 1979
- Airframe hours: 5137.2
- Engines: LYCOMING 0-320-D3G 160 horsepower reciprocating
- Damage: Substantial damage
- Flight: Personal, Part 91
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, September 1, 2014, 135 hours before
- Departed: ALX, Alexander City, AL
- Destination: 71J, Ozark, AL
- Airport: ALX, Thomas C. Russell Field
- Equipment: Stall warning system

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 38; injuries: minor; commercial, flight instructor, private; airplane ratings: single-engine land; instrument ratings: helicopter; medical: class 2; last flight review May 2, 2014; seat: left; restraint: none; flight hours: 1,043 total, 283 in this make and model, 330 as pilot in command

## Weather

- Conditions: Visual (VMC), Night/dark
- Wind: calm
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 45 °F, dew point 25 °F
- Altimeter: 30.14 inHg
- Observed at: KALX

## FAA reports on this event (1)

The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs).

- [Accident 20150118000769A](https://openairdocs.org/incident/20150118000769A), Jan 18, 2015: Piper PA-28-161, Alexander City, AL, Substantial damage. Pilot flew from khsv kalx. Taxied and shut down at self service pumps. Noticed battery low. Did not set brakes or chalk aircraft. Fuel/primed engine 8 times.…

## Docket (11 files)

The files NTSB released with the investigation on June 29, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=90620. 17.8 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40428587&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF
- Record of Conversation - Pilot Statement (item 2, .PDF, 187 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40428588&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Pilot%20Statement-Master.PDF
- Satellite Image of Accident Location with Superimposed Ground Track – Courtesy of FAA (item 3, .PDF, 1 photo, 166 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40428589&FileExtension=.PDF&FileName=Satellite%20Image%20of%20Accident%20Location%20with%20Superimposed%20Ground%20Track%20%E2%80%93%20Courtesy%20of%20FAA-Master.PDF
- Weather Reports and Records – KALX METARs (item 4, .PDF, 342 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40428590&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records%20%E2%80%93%20KALX%20METARs-Master.PDF
- Weather Reports and Records – US Naval Observatory Astronomical Data (item 5, .PDF, 36 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40428591&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records%20%E2%80%93%20US%20Naval%20Observatory%20Astronomical%20Data-Master.PDF
- Photo 1 - Main Wreckage (Photo Courtesy of FAA) (item 6, .PDF, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40428592&FileExtension=.PDF&FileName=Photo%201%20-%20Main%20Wreckage%20(Photo%20Courtesy%20of%20FAA)-Master.PDF
- Photo 2 - Right Side of Main Wreckage (Photo Courtesy of FAA) (item 7, .PDF, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40428593&FileExtension=.PDF&FileName=Photo%202%20-%20Right%20Side%20of%20Main%20Wreckage%20(Photo%20Courtesy%20of%20FAA)-Master.PDF
- Photo 3 - Rear of Main Wreckage (Photo Courtesy of FAA) (item 8, .PDF, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40428594&FileExtension=.PDF&FileName=Photo%203%20-%20Rear%20of%20Main%20Wreckage%20(Photo%20Courtesy%20of%20FAA)-Master.PDF
- Photo 4 - Left Wing Tip (Photo Courtesy of FAA) (item 9, .PDF, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40428595&FileExtension=.PDF&FileName=Photo%204%20-%20Left%20Wing%20Tip%20(Photo%20Courtesy%20of%20FAA)-Master.PDF
- Photo 5 - Left Wing (Photo Courtesy of FAA) (item 10, .PDF, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40428596&FileExtension=.PDF&FileName=Photo%205%20-%20Left%20Wing%20(Photo%20Courtesy%20of%20FAA)-Master.PDF
- Photo 6 - Right Wing Root (Photo Courtesy of FAA) (item 11, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40428597&FileExtension=.PDF&FileName=Photo%206%20-%20Right%20Wing%20Root%20(Photo%20Courtesy%20of%20FAA)-Master.PDF

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

---
OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.